State Form Number (SFN) 54049

Employment Retaliation (Whistleblower) Questionnaire/Affidavit Form

Instructions for SFN 54049

Please answer the items on the questionnaire completely and specifically so that we can fully assess your situation.
Please type or write your answers legibly, using additional paper if necessary. Incomplete questionnaires will be
returned for completion. Copies of any records or documents you have that support your claim should also be submitted
with the completed questionnaire.

If the department determines that it does have a legal basis to proceed, it will generate a formal complaint, which
will be mailed to you. You will be asked to review the complaint, sign it, and return it to the Department of Labor and Human Rights.
The department may attempt to obtain voluntary compliance through informal advice, negotiation, or conciliation.

If the department determines that it does not have a legal basis to proceed, you will be notified in writing and
given the opportunity to provide further information if applicable. Please be advised that there are many unfair acts
that do not constitute unlawful retaliation.

Timeliness is important when filing your concerns. There is a 300-day limitation, from the date of the alleged
discriminatory act, within which the signed formal complaint must be returned to the department. Keep in mind that the
intake questionnaire must be submitted in time to allow the department to assess the initial information, acquire any
additional information necessary, and process a formal complaint before the time limit expires.